Subjective — Simple/Additional HPI, ROS, and Questionnaires — Adult Visit

[checkbox name="additionalhx" memo="HPI/ADDITIONAL HX" memo_size="large" value=""][conditional field="additionalhx" condition="(additionalhx).is('')"]
[select name="hpi" value="|History of Present Illness|Problem History:" memo="optional title"] [/conditional][conditional field="hpi" condition="(hpi).is('Problem History:')"][text memo="Problem"][/conditional][conditional field="additionalhx" condition="(additionalhx).is('')"]
[checkbox name="addlhxfreetext" memo="freetext" memo_size="small" value=""][/conditional][conditional field="addlhxfreetext" condition="(addlhxfreetext).is('')"][textarea rows="4"][/conditional][conditional field="additionalhx" condition="(additionalhx).is('')"][checkbox name="addlhxformatted" memo="preformatted" memo_size="small" value=""][/conditional][conditional field="addlhxformatted" condition="(addlhxformatted).is('')"][select value="He=0|She=1" name="sex"] additionally reports [text size="50"]. Symptoms started [text size="3"] [select value="hour(s)|day(s)|week(s)|month(s)|year(s)"] ago. [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"] reports these symptoms are located [text size="35"]. [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"] reports these symptoms are [select value="getting worse|getting better|the same"] since onset. Rates it as [text size="4"]/10 in severity.  Describes the character/quality as [checkbox value="sharp|dull|burning|tingling|N/A"][text size="80"]. These sx [select value="do not travel/radiate|travel/radiate to"] [text size="25"]. [select name="Associated" value="Denies any associated symptoms.|Reports these associated symptoms that started around the same time-"][/conditional][conditional field="Associated" condition="(Associated).is('Reports these associated symptoms that started around the same time-')"] [text size="25"][/conditional][conditional field="addlhxformatted" condition="(addlhxformatted).is('')"] Symptoms are improved with [text size ="80"].  Symptoms are worsened by [text size="80"].  [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"] [select value="denies|admits to"] history of similar symptoms previously.[/conditional][conditional field="additionalhx" condition="(additionalhx).is('')"]

[/conditional][checkbox name="MasterROS"  memo="ROS" memo_size="large" value=""][conditional field="MasterROS" condition="(MasterROS).is('')"]Review of Systems
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="constitutional" name="constitutional" value=""][/conditional][conditional field="constitutional" condition="(constitutional).is('')"]constitutional symptoms: [select value="denies|endorses"] fever, [select value="denies|endorses"] weight loss, [select value="denies|endorses"] extreme fatigue. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="eyes" name="eyes" value=""][/conditional][conditional field="eyes" condition="(eyes).is('')"]eyes:	[select value="denies|endorses"] double vision, [select value="denies|endorses"] sudden loss of vision. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="HEENT" name="HEENT" value=""][/conditional][conditional field="HEENT" condition="(HEENT).is('')"]ears, nose, mouth, throat: [select value="denies|endorses"] sore throat, [select value="denies|endorses"] runny nose, [select value="denies|endorses"] ear pain. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="cardiovascular" name="cardiovascular" value=""][/conditional][conditional field="cardiovascular" condition="(cardiovascular).is('')"]cardiovascular: [select value="denies|endorses"] chest pain, [select value="denies|endorses"] palpitations. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="respiratory" name="respiratory" value=""][/conditional][conditional field="respiratory" condition="(respiratory).is('')"]respiratory: [select value="denies|endorses"] cough, [select value="denies|endorses"] wheezing, [select value="denies|endorses"] shortness of breath. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="gastrointestinal" name="gastrointestinal" value=""][/conditional][conditional field="gastrointestinal" condition="(gastrointestinal).is('')"]gastrointestinal: [select value="denies|endorses"] nausea, [select value="denies|endorses"] vomiting, [select value="denies|endorses"] abdominal pain, [select value="denies|endorses"] constipation, [select value="denies|endorses"] diarrhea, [select value="denies|endorses"] blood in stools. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="genitourinary" name="genitourinary" value=""][/conditional][conditional field="genitourinary" condition="(genitourinary).is('')"]genitourinary: [select value="denies|endorses"] urinary frequency, [select value="denies|endorses"] urinary urgency, [select value="denies|endorses"] pain with voiding, [checkbox memo_color=blue memo="Male symptoms" name="male" value=""][/conditional][conditional field="male" condition="(male).is('')"][select value="denies|endorses"] penile discharge.[/conditional] [conditional field="genitourinary" condition="(genitourinary).is('')"][checkbox memo_color=blue memo="Female symptoms" name="female" value=""][/conditional][conditional field="female" condition="(female).is('')"] [select value="denies|endorses"] vaginal discharge, [select value="denies|endorses"] painful intercourse.[/conditional] [conditional field="genitourinary" condition="(genitourinary).is('')"][textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="skin" name="skin" value=""][/conditional][conditional field="skin" condition="(skin).is('')"]skin: [select value="denies|endorses"] rash, [select value="denies|endorses"] changing mole. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="sleep" name="sleep" value=""][/conditional][conditional field="sleep" condition="(sleep).is('')"]sleep: [select value="denies|endorses"] snoring, [select value="denies|endorses"] difficulty sleeping. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="neurological" name="neurological" value=""][/conditional][conditional field="neurological" condition="(neurological).is('')"]neurological: [select value="denies|endorses"] headache, [select value="denies|endorses"] dizziness, [select value="denies|endorses"] weakness, [select value="denies|endorses"] imbalance, [select value="denies|endorses"] numbness, [select value="denies|endorses"] tingling, [select value="denies|endorses"] swallowing difficulty. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="musculoskeletal" name="musculoskeletal" value=""][/conditional][conditional field="musculoskeletal" condition="(musculoskeletal).is('')"]musculoskeletal: [select value="denies|endorses"] joint pain, [select value="denies|endorses"] muscle pain, [select value="denies|endorses"] muscle weakness. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="psychiatric" name="psychiatric" value=""][/conditional][conditional field="psychiatric" condition="(psychiatric).is('')"]psychiatric: [select value="denies|endorses"] depression, [select value="denies|endorses"] anxiety, [select value="denies|endorses"] suicidal thoughts. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="endocrine" name="endocrine" value=""][/conditional][conditional field="endocrine" condition="(endocrine).is('')"]endocrine: [select value="denies|endorses"] excessive thirst, [select value="denies|endorses"] cold or heat intolerance, [select value="denies|endorses"] breast mass. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][checkbox memo_color=blue memo="hematologic" name="hematologic" value=""][/conditional][conditional field="hematologic" condition="(hematologic).is('')"]hematologic: [select value="denies|endorses"] unusual bruising or bleeding, [select value="denies|endorses"] enlarged lymph nodes. [textarea memo_color=blue memo="explanation of abnormals if needed" memo_size="small" memo_color="orange" rows="2"]
[/conditional][conditional field="MasterROS" condition="(MasterROS).is('')"][comment memo="End of Review of Systems"]
[/conditional][checkbox memo="PHQ-9" name="PHQ9" value=""][conditional field="PHQ9" condition="(PHQ9).is('')"]Patient Health Questionnaire PHQ-9 - Depression Screen
[select name="phqQ1" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #1 Little interest or pleasure in doing things over the last 2 weeks
[select name="phqQ2" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #2 Feeling down, depressed or hopeless over the last 2 weeks
[select name="phqQ3" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #3 Trouble falling or staying asleep, or sleeping too much over the last weeks
[select name="phqQ4" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #4 Feeling tired or having little energy over the last 2 weeks
[select name="phqQ5" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #5 Poor appetite or overeating over the last 2 weeks
[select name="phqQ6" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #6 Feeling bad about self-or are a failure or have let self or family down over the last 2 weeks
[select name="phqQ7" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #7 Trouble concentrating on things, such as reading the newspaper or watching television over the last 2 weeks
[select name="phqQ8" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #8 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that has been moving around a lot more than usual over the last 2 weeks
[select name="phqQ9" value="not at all (0 points)=0|several days (1 point)=1|more than half the days (2 points)=2|nearly every day (3 points)=3"] <-- #9 Thoughts that would be better off dead or of hurting self in some way over the last 2 weeks
Score --> [calc value="score=(phqQ1)+(phqQ2)+(phqQ3)+(phqQ4)+(phqQ5)+(phqQ6)+(phqQ7)+(phqQ8)+(phqQ9)" memo="score"] out of 27 points. Interpretation --> [calc value="phqscore1=(phqQ1)+(phqQ2)+(phqQ3)+(phqQ4)+(phqQ5)+(phqQ6)+(phqQ7)+(phqQ8)+(phqQ9);phqscore1>20?'Severe':phqscore1>14?'Moderately Severe':phqscore1>9?'Mild':phqscore1>4?'Minimal Symptoms':'Asymptomatic'" memo="interpretation"]
[checkbox memo="display/hide references" name="footnotesPHQ9" value=""][/conditional][conditional field="footnotesPHQ9" condition="(footnotesPHQ9).is('')"]
reference: [link url="http://www.ncbi.nlm.nih.gov/pubmed/11556941" memo="#1"] Kroenke (2001) J Gen Intern Med 16:606-13.

[/conditional][checkbox memo="GAD-7" name="GAD7" value=""][conditional field="GAD7" condition="(GAD7).is('')"]GAD-7 Questionnaire
[select name="gadQ1" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Feeling nervous, anxious or on edge (over the last two weeks)?
[select name="gadQ2" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Being unable to stop or control worrying (over the last two weeks)?
[select name="gadQ3" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Worrying too much about different things (over the last two weeks)?
[select name="gadQ4" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Having trouble relaxing (over the last two weeks)?
[select name="gadQ5" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Being so restless that it is hard to sit still (over the last two weeks)?
[select name="gadQ6" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Becoming easily annoyed or irritable (over the last two weeks)?
[select name="gadQ7" value="Not at all (0 points)=0|Several days (1 points)=1|More than half the days (2 points)=2|Nearly everyday (3 points)=3"] <-- Feeling afraid, as if something awful might happen (over the last two weeks)?
Score --> [calc value="score=(gadQ1)+(gadQ2)+(gadQ3)+(gadQ4)+(gadQ5)+(gadQ6)+(gadQ7)" memo="score"] out of 21 points
Interpretation --> [calc value="gad7score1=(gadQ1)+(gadQ2)+(gadQ3)+(gadQ4)+(gadQ5)+(gadQ6)+(gadQ7);gad7score1>8?'suggestive of anxiety or panic disorder':gad7score1>0?'mild symptoms':'asymptomatic'" memo="interpretation"]
[checkbox memo="references" name="gad7footnotes" value=""][/conditional][conditional field="gad7footnotes" condition="(gad7footnotes).is('')"]references:
[link url="http://www.ncbi.nlm.nih.gov/pubmed/16717171" memo="#1"] Spitzer RL, Kroenke K, Williams JB, Löwe B. Arch Intern Med. 2006 May 22;166(10):1092-7. A brief measure for assessing generalized anxiety disorder: the GAD-7
[link url="http://www.aafp.org/afp/2008/0815/p501.html" memo="#2"] Am Fam Physician. 2008 Aug 15;78(4):501-502

[/conditional][checkbox memo="Adult ASRS (ADHD) Initial Questionnaire" name="ASRSinitial" value=""][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]Adult ADHD Self-Report Scale
Section A (SCREEN)
[select name="asrsQ1" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 1. Trouble wrapping up the final details of a project, once the challenging parts have been done?
[select name="asrsQ2" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 2. Difficulty getting things in order when you have to do a task that requires organization?
[select name="asrsQ3" value="never=0|rarely=0|sometimes=1|often=1|very often=1"] <-- 3. Problems remembering appointments or obligations?
[select name="asrsQ4" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
[select name="asrsQ5" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 5. Fidget or squirm with your hands or feet when you have to sit down for a long time?
[select name="asrsQ6" value="never=0|rarely=0|sometimes=0|often=1|very often=1"] <-- 6. Feel overly active and compelled to do things, like you were driven by a motor?

[checkbox name="ASRSseverity" value="" memo="Complete and score Section B (SEVERITY) if above screen positive"][/conditional][conditional field="ASRSseverity" condition="(ASRSseverity).is('')"]
Section B (SEVERITY)
[select name="asrsQ7" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 7. Make careless mistakes when you have to work on a boring or difficult project?
[select name="asrsQ8" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 8. Difficulty keeping your attention when you are doing boring or repetitive work?
[select name="asrsQ9" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 9. Difficulty concentrating on what people say to you, even when they are speaking to you directly?
[select name="asrsQ10" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 10. Misplace or have difficulty finding things at home or at work?
[select name="asrsQ11" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 11. Distracted by activity or noise around you?
[select name="asrsQ12" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 12. Leave your seat in meetings or other situations in which you are expected to remain seated?
[select name="asrsQ13" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 13. Feel restless or fidgety?
[select name="asrsQ14" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 14. Difficulty unwinding and relaxing when you have time to yourself?
[select name="asrsQ15" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 15. Talking too much when you are in social situations?
[select name="asrsQ16" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 16. Finishing the sentences of the people you are talking to, before they can finish them themselves?
[select name="asrsQ17" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 17. Difficulty waiting your turn in situations when turn taking is required?
[select name="asrsQ18" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 18. Interrupt others when they are busy?

[/conditional][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]Section A (SCREEN) Result –-> [calc value="asrsscore1=(asrsQ1)+(asrsQ2)+(asrsQ3)+(asrsQ4)+(asrsQ5)+(asrsQ6);asrsscore1>3?'Section A - Symptoms highly consistent with ADHD in adults, further investigation is warranted':'Section A - Negative screen for ADHD, consider other diagnoses'" memo="interpretation" memo_size="small" ][/conditional][conditional field="ASRSseverity" condition="(ASRSseverity).is('')"]

Section B (SEVERITY) Result --> [calc value="asrsscore2=+(asrsQ7)+(asrsQ8)+(asrsQ9)+(asrsQ10)+(asrsQ11)+(asrsQ12)+(asrsQ13)+(asrsQ14)+(asrsQ15)+(asrsQ16)+(asrsQ17)+(asrsQ18);asrsscore2>47?'Section B - Average frequency of symptoms = VERY OFTEN':asrsscore2>35?'Section B - Average frequency of symptoms = OFTEN':asrsscore2>23?'Section B - Average frequency of symptoms = SOMETIMES':asrsscore2>11?'Section B - Average frequency of symptoms = RARELY':'Section B - Average frequency of symptoms = NEVER'" memo="interpretation"][/conditional][conditional field="ASRSinitial" condition="(ASRSinitial).is('')"]
[checkbox memo="references" name="ASRSfootnotes" value=""]

[/conditional][conditional field="ASRSfootnotes" condition="(ASRSfootnotes).is('')"]reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/15841682" memo="#1"] Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005 Feb;35(2):245-56.
[link url="http://www.aafp.org/afp/2012/0501/p890.html memo="#2"] Post RE, Kurlansik SL. Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. Am Fam Phys. 2012 May 1;85(9):890-896.

[/conditional][checkbox memo="Adult followup ASRS Questionnaire" name="ASRSfollowup" value=""][conditional field="ASRSfollowup" condition="(ASRSfollowup).is('')"]Adult ADHD Self-Report Scale

[select name="asrsfuQ7" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 7. Make careless mistakes when you have to work on a boring or difficult project?
[select name="asrsfuQ8" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 8. Difficulty keeping your attention when you are doing boring or repetitive work?
[select name="asrsfuQ9" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 9. Difficulty concentrating on what people say to you, even when they are speaking to you directly?
[select name="asrsfuQ10" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 10. Misplace or have difficulty finding things at home or at work?
[select name="asrsfuQ11" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 11. Distracted by activity or noise around you?
[select name="asrsfuQ12" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 12. Leave your seat in meetings or other situations in which you are expected to remain seated?
[select name="asrsfuQ13" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 13. Feel restless or fidgety?
[select name="asrsfuQ14" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 14. Difficulty unwinding and relaxing when you have time to yourself?
[select name="asrsfuQ15" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 15. Talking too much when you are in social situations?
[select name="asrsfuQ16" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 16. Finishing the sentences of the people you are talking to, before they can finish them themselves?
[select name="asrsfuQ17" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 17. Difficulty waiting your turn in situations when turn taking is required?
[select name="asrsfuQ18" value="never=0|rarely=1|sometimes=2|often=3|very often=4"] <-- 18. Interrupt others when they are busy?

Result --> [calc value="asrsfuscore2=+(asrsfuQ7)+(asrsfuQ8)+(asrsfuQ9)+(asrsfuQ10)+(asrsfuQ11)+(asrsfuQ12)+(asrsfuQ13)+(asrsfuQ14)+(asrsfuQ15)+(asrsfuQ16)+(asrsfuQ17)+(asrsfuQ18);asrsfuscore2>47?'Section B - Average frequency of symptoms = VERY OFTEN':asrsfuscore2>35?'Section B - Average frequency of symptoms = OFTEN':asrsfuscore2>23?'Section B - Average frequency of symptoms = SOMETIMES':asrsfuscore2>11?'Section B - Average frequency of symptoms = RARELY':'Section B - Average frequency of symptoms = NEVER'" memo="interpretation"]
[checkbox memo="references" name="asrsfufootnotes" value=""]

[/conditional][conditional field="asrsfufootnotes" condition="(asrsfufootnotes).is('')"]
reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/15841682" memo="#1"] Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, Howes MJ, Jin R, Secnik K, Spencer T, Ustun TB, Walters EE. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005 Feb;35(2):245-56.
[link url="http://www.aafp.org/afp/2012/0501/p890.html memo="#2"] Post RE, Kurlansik SL. Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Adults. Am Fam Phys. 2012 May 1;85(9):890-896.

[/conditional][checkbox memo="Asthma Severity Classification" name="AsthmaSeverity" value=""][conditional field="AsthmaSeverity" condition="(AsthmaSeverity).is('')"]Asthma Severity Classification[comment memo="For [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"]s NOT currently taking long-term control medication"]
[select name="asthmasevAge" value="|5 to 11 years|12 years and above"] <-- Age
[/conditional][conditional field="asthmasevAge" condition="(asthmasevAge).is('5 to 11 years')"][select name="asthmasevImpSymp1" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Throughout the day=1000"] <-- Impairment - Symptoms
[select name="asthmasevImpNA1" value="Up to 2 times per month=1|3 to 4 times per month=10|More than 1 time per week, but not nightly=100|Often 7 times a week=1000"] <-- Impairment - Nighttime awakenings
[select name="asthmasevImpSA1" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Several times per day=1000"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmasevImpNorm1" value="None=1|Minor limitation=10|Some limitation=100|Extremely limited=1000"] <-- Impairment - Interference with normal activity
[select name="asthmasevImpLF1" value="Normal FEV1 between exacerbations, FEV1 more than 80% predicted, FEV1 to FVC more than 85%=1|FEV1 80% or more than predicted, FEV1 to FVC more than 80%=10|FEV1 60 to 80% predicted, FEV1 to FVC 75 to 80% predicted=100|FEV1 less than 60% predicted, FEV1 to FVC less than 75% predicted=1000"] <-- Impairment - Lung function
[select name="asthmasevRisk1" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Interpretation --> [calc memo="Severity" value="asthmaSCscore1=(asthmasevImpSymp1)+(asthmasevImpNA1)+(asthmasevImpSA1)+(asthmasevImpNorm1)+(asthmasevImpLF1)+(asthmasevRisk1);asthmaSCscore1>999?'Severe Persistent Asthma':asthmaSCscore1>99?'Moderate Persistent Asthma':asthmaSCscore1>9?'Mild Persistent Asthma':'Intermittent Asthma'"]
[link url="/wp-content/uploads/2018/08/asthma-steps-kids.jpg" memo="Stepwise medication table for children 5-11 years"][/conditional][conditional field="asthmasevAge" condition="(asthmasevAge).is('12 years and above')"][select name="asthmasevImpSymp2" value="Up to 2 days per week=1|More than 2 days per week, but not daily=10|Daily=100|Throughout the day=1000"] <-- Impairment - Symptoms
[select name="asthmasevImpNA2" value="Up to 2 times per month=1|3 to 4 times per month=10|More than 1 time per week, but not nightly=100|Often 7 times per week=1000"] <-- Impairment - Nighttime awakenings
[select name="asthmasevImpSA2" value="Up to 2 days per week=1|More than 2 days per week but not daily, and not more than 1 time on any day=10|Daily=100|Several times per day=1000"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmasevImpNorm2" value="None=1|Minor limitation=10|Some limitation=100|Extremely limited=1000"] <-- Impairment - Interference with normal activity
[select name="asthmasevImpLF2" value="Normal FEV1 between exacerbations, FEV1 more than 80% predicted, FEV1 to FVC normal=1|FEV1 80% or more than predicted, FEV1 to FVC normal=10|FEV1 more than 60% but less than 80%, FEV1 to FVC reduced 5%=100|FEV1 less than 60% predicted, FEV1 to FVC reduced more than 5%=1000"] <-- Impairment - Lung function
Normal FEV1/FVC: 8-19 yr 85 percent; 20-39 yr 80 percent; 40-59 yr 75 percent; 60-80 yr 70 percent
[select name="asthmasevRisk2" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Interpretation --> [calc memo="Severity" value="asthmaSCscore2=(asthmasevImpSymp2)+(asthmasevImpNA2)+(asthmasevImpSA2)+(asthmasevImpNorm2)+(asthmasevImpLF2)+(asthmasevRisk2);asthmaSCscore2>999?'Severe Persistent Asthma':asthmaSCscore2>99?'Moderate Persistent Asthma':asthmaSCscore2>9?'Mild Persistent Asthma':'Intermittent Asthma'"]
[link url="/wp-content/uploads/2018/08/asthma-steps-adults.jpg" memo="Stepwise medication table for ages 12+ years"][/conditional][conditional field="AsthmaSeverity" condition="(AsthmaSeverity).is('')"]
[checkbox memo="display/hide references" name="footnotes" value=""]

[conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma" memo="#1"] National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) 2007 Guidelines 2007 Guidelines
[link url="//www.ncbi.nlm.nih.gov/pubmed/20141095" memo="#2"] Pollart (2009) Am Fam Physician 79: 761-7.

[/conditional][checkbox memo="Asthma Control Classification & Recommendations" name="AsthmaControl" value=""][conditional field="AsthmaControl" condition="(AsthmaControl).is('')"]Asthma Control Classification & Recommendations[comment memo="for [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"]s currently taking long-term control medication" memo_size="small"]
[select name="asthmacontrAge" value="|5 to 11 years|12 years and above"] <-- Age
[/conditional][conditional field="asthmacontrAge" condition="(asthmacontrAge).is('5 to 11 years')"][select name="asthmacontrImpSymp1" value="Up to 2 days per week, but not more than once on each day=1|More than 2 days per week or multiple times on up to 2 days per week=10|Throughout the day=100"] <-- Impairment - Symptoms
[select name="asthmacontrImpNA1" value="Up to 1 time per month=1|2 or more times per month=10|2 or more times per week=100"] <-- Impairment - Nighttime awakenings
[select name="asthmacontrImpSA1" value="Up to 2 days per week=1|More than 2 days per week=10|Several times per day=100"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmacontrImpNorm1" value="None=1|Some limitation=10|Extremely limited=100"] <-- Impairment - Interference with normal activity
[select name="asthmacontrImpLF1" value="FEV1 more than 80% predicted, Peak Flow more than 80% personal best, FEV1 to FVC more than 80%=1|FEV1 60 to 80% predicted, Peak Flow 60 to 80% personal best, FEV1 to FVC 75 to 80%=10|FEV1 less than 60% predicted, Peak Flow less than 60% personal best, FEV1 to FVC less than 75%=100"] <-- Impairment - Lung Function
[select name="asthmacontrRisk1" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Recommendations --> [calc memo="Interpretation" value="asthmaCRscore1=(asthmacontrImpSymp1)+(asthmacontrImpNA1)+(asthmacontrImpSA1)+(asthmacontrImpNorm1)+(asthmacontrImpLF1)+(asthmacontrRisk1);asthmaCRscore1>99?'Very Poorly Controlled Asthma: Consider short course of oral systemic corticosteroids; step up one to two steps, and reevaluate in two weeks.':asthmaCRscore1>9?'Not Well-Controlled Asthma: Step up one step and reevaluate in two to six weeks.':'Well-Controlled Asthma: Maintain current step; regular follow-up every one to six months to maintain control; consider step down if well controlled for at least three months.'"]
[link memo="Stepwise medication table for children 5-11 years" url="//www.soapnote.org/wp-content/uploads/2018/08/asthma-steps-kids.jpg"]
[/conditional][conditional field="asthmacontrAge" condition="(asthmacontrAge).is('12 years and above')"][select name="asthmacontrImpSymp2" value="Up to 2 days per week=1|More than 2 days per week=10|Throughout the day=100"] <-- Impairment - Symptoms
[select name="asthmacontrImpNA2" value="Up to 2 times per month=1|1 to 3 times per week=10|4 or more times per week=100"] <-- Impairment - Nighttime awakenings
[select name="asthmacontrImpSA2" value="Up to 2 days per week=1|More than 2 days per week=10|Several times per day=100"] <-- Impairment - Short-acting beta2-agonist use for symptom control (not prevention of exercise induced bronchospasm)
[select name="asthmacontrImpNorm2" value="None=1|Some limitation=10|Extremely limited=100"] <-- Impairment - Interference with normal activity
[select name="asthmacontrImpLF2" value="FEV1 more than 80% predicted, Peak Flow more than 80% personal best=1|FEV1 60 to 80% predicted, Peak Flow 60 to 80% personal best=10|FEV1 less than 60% predicted, Peak Flow less than 60% personal best=100"] <-- Impairment - Lung Function
[select name="asthmacontrImpQ2" value="ATAQ of 0 OR ACQ less than or equal to 0.75 OR ACT greater than or equal to 20 OR soapnote Generic equal to 0=1|ATAQ of 1 to 2 OR ACQ greater than or equal to 1.5 OR ACT of 16 to 19 OR soapnote Generic greater than or equal to 1=10|ATAQ of 3 to 4 OR ACT less than or equal to 15=100"] <-- Impairment - Questionnaires
[select name="asthmacontrRisk2" value="0 to 1 per year=1|2 or more per year=10"] <-- Risk - Exacerbations requiring oral systemic corticosteroids
Recommendations --> [calc memo="Interpretation" value="asthmaCRscore2=(asthmacontrImpSymp2)+(asthmacontrImpNA2)+(asthmacontrImpSA2)+(asthmacontrImpNorm2)+(asthmacontrImpLF2)+(asthmacontrImpQ2)+(asthmacontrRisk2);asthmaCRscore2>99?'Very Poorly Controlled Asthma: Consider short course of oral systemic corticosteroids; step up one to two steps, and reevaluate in two weeks.':asthmaCRscore2>9?'Not Well-Controlled Asthma: Step up one step and reevaluate in two to six weeks.':'Well-Controlled Asthma: Maintain current step; regular follow-up every one to six months to maintain control; consider step down if well controlled for at least three months.'"]
[link memo="Stepwise medication table for ages 12+ years" url="//www.soapnote.org/wp-content/uploads/2018/08/asthma-steps-adults.jpg"]

[/conditional][conditional field="AsthmaControl" condition="(AsthmaControl).is('')"]
[checkbox memo="references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]reference:
[link url="//www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma" memo="#1"] National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) 2007 Guidelines 2007 Guidelines
[link url="//www.ncbi.nlm.nih.gov/pubmed/20141095" memo="#2"] Pollart (2009) Am Fam Physician 79: 761-7.

[/conditional][checkbox memo="Epworth Sleepiness Scale" name="Epworth" value=""][conditional field="Epworth" condition="(Epworth).is('')"]Epworth Sleepiness Scale
[select name="epQ1" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are sitting and reading
[select name="epQ2" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are watching television
[select name="epQ3" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are sitting inactive at a public place (e.g., in a theater, during a meeting)
[select name="epQ4" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are a passenger in a car riding for an hour without breaks
[select name="epQ5" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are lying down in the afternoon when circumstances permit
[select name="epQ6" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are sitting and talking to someone
[select name="epQ7" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are sitting quietly after lunch without alcohol
[select name="epQ8" value="No chance (0 points)=0|Slight chance (1 point)=1|Moderate chance (2 points)=2|High chance (3 points)=3"] <-- Rate the chance you will doze off while you are in a car while stopped for a few minutes in traffic
[calc value="epscore1=(epQ1)+(epQ2)+(epQ3)+(epQ4)+(epQ5)+(epQ6)+(epQ7)+(epQ8)" memo="score"] out of 24 points --> [calc value="epscore1=(epQ1)+(epQ2)+(epQ3)+(epQ4)+(epQ5)+(epQ6)+(epQ7)+(epQ8);epscore1>15?'severe sleepiness - further evaluation recommended for significant daytime sleepiness':epscore1>11?'moderate sleepiness - further evaluation recommended for significant daytime sleepiness':epscore1>7?'mild sleepiness':'normal daytime alertness'" memo="interpretation"]

[checkbox memo="display/hide references" name="footnotes" value=""][/conditional][conditional field="footnotes" condition="(footnotes).is('')"]
references:
[link url="//www.ncbi.nlm.nih.gov/pubmed/1798888" memo="#1"] Johns (1991) Sleep 14(6): 540-5
[link url="//www.aafp.org/afp/2009/0301/p391.html" memo="#2"] Pagel (2009) Am Fam Physician 79(5):391-396
[link url="//www.fpnotebook.com/psych/exam/EpwrthSlpnsScl.htm" memo="#1"] FP Notebook Page[/conditional][checkbox memo="STOP-BANG Questionnaire for Obstructive Sleep Apnea" name="StopBang" value=""][conditional field="StopBang" condition="(StopBang).is('')"]STOP-BANG Questionnaire for Obstructive Sleep Apnea
[select name="sbQ1" value="no=0|YES=1"] <-- 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
[select name="sbQ2" value="no=0|YES=1"] <-- 2. Do you often feel TIRED, fatigued, or sleepy during daytime?
[select name="sbQ3" value="no=0|YES=1"] <-- 3. Has anyone OBSERVED you stop breathing during your sleep?
[select name="sbQ4" value="no=0|YES=1"] <-- 4. Do you have or are you being treated for high blood PRESSURE?
[select name="sbQ5" value="no=0|YES=1"] <-- 5. BMI more than 35?
[select name="sbQ6" value="no=0|YES=1"] <-- 6. AGE over 50 years old?
[select name="sbQ7" value="no=0|YES=1"] <-- 7. NECK circumference > 15.75 inches?
[select name="sbQ8" value="no=0|YES=1"] <-- 8. Male GENDER?

Score --> [calc memo="number" value="sbscore0=(sbQ1)+(sbQ2)+(sbQ3)+(sbQ4)+(sbQ5)+(sbQ6)+(sbQ7)+(sbQ8)"] / 8
Interpretation --> [calc memo="result" value="sbscore1=(sbQ1)+(sbQ2)+(sbQ3)+(sbQ4)+(sbQ5)+(sbQ6)+(sbQ7)+(sbQ8);sbscore1>2?'High Risk for Obstructive Sleep Apnea':'Low Risk for Obstructive Sleep Apnea'"]

[checkbox memo="display/hide references" name="footnotes" value=""][/conditional][conditional field="footnotes" condition="(footnotes).is('')"]
reference: [link memo="#1" url="http://www.ncbi.nlm.nih.gov/pubmed/18431116"] Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. STOP questionnaire: a tool to screen [calc memo="He/She" value="sexscore=(sex);sexscore=1?'She':'He'"]s for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21[/conditional][checkbox memo="Insomnia Severity Index" name="ISI" value=""][conditional field="ISI" condition="(ISI).is('')"]Insomnia Severity Index
[select name="isiQ1" value="none=0|mild=1|moderate=2|severe=3|very severe=4"] <-- 1. Difficulty falling asleep?
[select name="isiQ2" value="none=0|mild=1|moderate=2|severe=3|very severe=4"] <-- 2. Difficulty staying asleep?
[select name="isiQ3" value="none=0|mild=1|moderate=2|severe=3|very severe=4"] <-- 3.  Problems waking up too early?
[select name="isiQ4" value="very satisfied=0|satisfied=1|moderately satisfied=2|dissatisfied=3|very dissatisfied=4"] <-- 4.  How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?
[select name="isiQ5" value="not at all noticeable=0|a little=1|somewhat=2|much=3|very much noticeable=4"] <-- 5.  How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?
[select name="isiQ6" value="not at all worried=0|a little=1|somewhat=2|much=3|very much worried=4"] <-- 6. How WORRIED/DISTRESSED are you about your current sleep problem?
[select name="isiQ7" value="not at all interfering=0|a little=1|somewhat=2|much=3|very much interfering=4"] <-- 7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

Score --> [calc memo="number" value="isiscore0=(isiQ1)+(isiQ2)+(isiQ3)+(isiQ4)+(isiQ5)+(isiQ6)+(isiQ7)"] / 28
Interpretation --> [calc memo="result" value="isiscore1=(isiQ1)+(isiQ2)+(isiQ3)+(isiQ4)+(isiQ5)+(isiQ6)+(isiQ7);isiscore1>21?'Clinical Insomnia (severe)':isiscore1>14?'Clinical Insomnia (moderate severity)':isiscore1>7?'Clinical Insomnia (Subthreshold Insomnia)':'No clinically significant insomnia'"]

[checkbox memo="display/hide references" name="footnotes" value=""][/conditional][conditional field="footnotes" condition="(footnotes).is('')"]
reference: [link memo="#1" url="https://www.ons.org/sites/default/files/InsomniaSeverityIndex_ISI.pdf"]  courtesy of www.myhealth.va.gov [/conditional]

[link url="https://www.soapnote.org" memo="Assessment section"]
HPI/ADDITIONAL HX ROS PHQ-9 GAD-7 Adult ASRS (ADHD) Initial Questionnaire Adult followup ASRS Questionnaire Asthma Severity Classification
display/hide references

Asthma Control Classification & Recommendations
references Epworth Sleepiness Scale STOP-BANG Questionnaire for Obstructive Sleep Apnea Insomnia Severity Index

Assessment section

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.88, 331 form elements, 10 text boxes, 15 text areas, 40 checkboxes, 150 drop downs, 21 links, 3 comments, 21 calculations, 71 conditionals, 219 total clicks
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